Dr.iqbal Orl Cases

Clinical Scenarios inOto-rhino-laryngology

A Problem Oriented Approach

First Edition

ISBN: 978-969-9340-01-7

PROF. DR. IQBAL HUSSAIN UDAIPURWALA MBBS., DLO., FCPS.

Professor and Head of the ENT DepartmentBahria University Medical & Dental College, Karachi.

Fellow and Examiner, College of Physicians & Surgeons Pakistan.Editor, Pakistan Journal of Otolaryngology and Head & Neck Surgery.

Visiting ENT Surgeon, Liaquat National Hospital, Habib Medical Centreand Zubaida Medical Centre, Karachi.

Clinical scenarios in oto-rhino-laryngology

II

Copyright Reserved

All rights are reserved with the publisher. No part of this publication may bereproduced, stored in a retrieval system, or transmitted, in any form or by any means,electronic, mechanical, photocopying, recording or otherwise, without the prior permissionof the publisher.

ISBN: 978-969-9340-01-7

Great care has been taken to maintain information contained in the volume. However,in view of the ongoing research and changes in the government rules and regulation and aconstant inflow of information, the author can not be held responsible for errors or for anyconsequences arising from the use of the information contained herein.

First Edition, 2011


III

Preface to the first edition

It is a moment of great pleasure for me to present first edition of this book. Clinicalsubjects are always difficult for the medical students because most of the text books are writtenaccording to the diseases or systems but when they deal with the patients, who always comewith some complaints. To correlate these complaints of the patients with the disease and tomake diagnosis is always difficult for them. This book is an endeavor to improve clinicalacumen and interpretation of a medical student.

All common diseases of oto-rhino-laryngology and head & neck are presented in theform of case discussions. A clinical scenario is presented first and then important points inhistory taking and clinical examination are described with clinical, provisional or differentialdiagnosis. How this patient will be investigated and how the diagnosis will be reached is thengiven. At the end important points related with the diseases is discussed briefly.

This book could not have been accomplished without the help and assistance of manypeople. I would like to express my sincerest gratitude to all my teachers and colleagues whogave me valuable guidance and suggestions in writing this textbook. My special thanks goesto Dr. Muhammad Shuja Farrukh, assistant professor of ENT, Dow University of HealthSciences, Karachi who gave me his utmost support and full time assistance in proof reading ofthe manuscript several times, as indeed in seeing it in the form of a print. I am thankful to Mr.Rehan Ahmed Khan and Mr. Rehan Zia of Hamdard University Hospital for their technicalservices and support in title designing and computer work. In the last but not least, I am gratefulto my wife Azra Iqbal and my daughters, Fatima, Saba and Zahra for their enormous supportand untiring efforts at every step of this work, without them it would not be possible to makethis idea into a reality.

I hope medical students will find it very useful in preparation of their final examinationin ENT as well as in their clinical practice. By no means it is perfect and there may be someambiguity in the text. Your suggestions and criticism are always welcome to improve thestandard of this book.

Karachi, 2011. IQBAL HUSSAIN UDAIPURWALA


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Foreward

What is special about this book written by Prof. Iqbal Hussain Udaipurwala, who isalready author of few books on oto-rhino-laryngology. Real time clinical scenario based bookis a smart scientific attempt for teaching and learning, which makes it interesting and exciting.Most traditional textbooks of oto-rhino-laryngology contain basic clinical and scientific factsthat forms the foundation of the speciality. While these text can provide an essential cornerstonefor the practice of oto-rhino-laryngology, applying this information to a clinical setting relieson sound judgement, presence of mind and clinical experience. Problem based learning forunder-graduate and post-graduate teaching is very rewarding and practical. Based on real timeclinical cases, which you can witness by actual clinical case, patient pathology and photographs,you get a confidence of trueness. This helps confidence building regarding diagnosis andmanagement.

I must commend the author, Prof. Iqbal Hussain Udaipurwala for contributing thisscientific book for learners, this is bound to enrich the readers mind and skill beyond hisexpectations.

PROF. SYED TIPU SULTANMBBS, DA (London), FFARCSI, FCPS (Hon.)

Professor of Anaesthesiology, critical care and pain management,Principal, Bahria University Medical & Dental College,

Council Member, College of Physicians & Surgeons, Pakistan,President, Pakistan Medical Association (centre).


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C O N T E N T S

SECTION I: EARCase 1- Boil in the ear 3Case 2- Foreign body of the ear 6Case 3- Wax in the ear 9Case 4- Pre-auricular sinus 12Case 5- Otomycosis 14Case 6- Maggots in the external auditory canal 16Case 7- Acute suppurative otitis media 18Case 8- CSOM with aural polyp 21Case 9- CSOM with cholesteatoma 24Case 10- CSOM with facial paralysis 28Case 11- Dry perforation of ear drum 31Case 12- Otitis media with effusion 34Case 13- Otosclerosis 38Case 14- Presbyacusis 42Case 15- Noise induced hearing loss 45Case 16- Meneires disease 48Case 17- Benign paroxysmal positional vertigo 51Case 18- Congenital deafness 54

SECTION II: NOSE & PARANASAL SINUSESCase 19- Deviated nasal septum 59Case 20- Nasal trauma with fracture 62Case 21- Antro-choanal polyp 66Case 22- Septal haematoma 70Case 23- Ethmoidal polypi 73Case 24- Septal adhesion 76Case 25- Allergic rhinitis 78Case 26- Foreign body of the nose 81Case 27- Boil in the nose 84


VI

Case 28- Epistaxis 86Case 29- Chronic rhino-sinusitis 89Case 30- Nasopharyngeal angiofibroma 92

SECTION III: ORAL CAVITY & PHARYNXCase 31- Chronic tonsillitis 99Case 32- Post-tonsillectomy haemorrhage 102Case 33- Quinsy 104Case 34- Enlarged adenoids 107Case 35- Papilloma of the cheek 110Case 36- Carcinoma of the cheek 113Case 37- Carcinoma of the tongue 117Case 38- Foreign body of the throat 120Case 39- Ranula 123

SECTION IV: LARYNX & TRACHEACase 40- Vocal nodules 127Case 41- Tracheostomy 130Case 42- Carcinoma of the larynx 133Case 43- Foreign body of the bronchus 138

SECTION V: HEAD & NECKCase 44- Ludwigs angina 143Case 45- Branchial cyst 146Case 46- Retro-pharyngeal abscess 149Case 47- Sub-mandibular salivary calculus 152Case 48- Parotid gland pleomorphic adenoma 155Case 49- Multinodular goiter (MNG) 158Case 50- Tuberculous cervical lymphadenopathy 162


Section IEAR

1

Case 1- Boil in the ear 3Case 2- Foreign body of the ear 6Case 3- Wax in the ear 9Case 4- Pre-auricular sinus 12Case 5- Otomycosis 14Case 6- Maggots in the external auditory canal 16Case 7- Acute suppurative otitis media 18Case 8- CSOM with aural polyp 21Case 9- CSOM with cholesteatoma 24Case 10- CSOM with facial paralysis 28Case 11- Dry perforation of ear drum 31Case 12- Otitis media with effusion 34Case 13- Otosclerosis 38Case 14- Presbyacusis 42Case 15- Noise induced hearing loss 45Case 16- Meneires disease 48Case 17- Benign paroxysmal positional vertigo 51Case 18- Congenital deafness 54

Clinical Scenario


Case 1

3

Important points in history taking:1- Any previous history of discharge from the ear. In this case there was no

such previous history.2- History of diabetes mellitus or other immuno-compromised states. In

this case no such history.3- Habit of scratching the ears with any sharp object. There was no such

history.4- Any history of swimming especially in dirty water. There was no such

history.

Important points in clinical examination:1- Palpation of tragus, pinna and mastoid area for tenderness. Tragus and

pinna were tender but mastoid area was not tender in this case.2- Probe test of the swelling. Swelling was very tender and soft. It was not

possible to move the probe all around the swelling i.e swelling is arisingfrom the canal wall in its outer cartilagenous part.

3- Tuning fork tests showed conductive type of deafness. Rinnes test wasnegative in the left ear and positive in the right ear, Webers test was

A 28 years male patient came in the OPD with complaint of pain in the left earfor last 2 days. Initially pain was mild to moderate but next day it increased and becamesevere. He also had deafness and swelling around the ear canal with some pussy discharge.On examination his left pinna was very tender especially over the tragus with yellowishpus coming out. On retraction of the pinna a rounded, soft and fluctuant swelling wasvisible at the external auditory meatus (fig. 1.1). It was not possible to examine deeperpart of the canal and tympanic membrane because of pain.

Fig. 1.1Rounded, soft, tender and fluctuant

swelling in the external auditorymeatus

lateralized towards the left and and Schwabachs test was equal to theexaminer in both ears.

Diagnosis:The most probable diagnosis of this case was Boil ear.

Differential Diagnosis:The differential diagnosis in this case could be:

1- Aural polyp: In aural polyp there is history of chronic discharging earfor a long time. In addition probe test will differentiate a polyp fromswelling arising from the external auditory canal.

2- Osteoma: This is a benign tumour of bony origin and is situated in thedeeper bony part of the external auditory canal. It is hard and usuallynon-tender.

Investigations:No investigation was done in this case.

Treatment:This was a case of large boil where pus was present along with

fluctuation and patient was already taking antibiotic without any relieve. Soincision and drainage was planned under local anaesthesia. A longitudinalincision was given parallel to the external auditory canal. Pus was drainedand sent for culture and sensitivity. The external auditory canal was packedwith antiseptic ointment. Antibiotic against staphylococcus aureus was givenparenterally (amoxicillin with clavulanic acid).

Pus drained after incision & drainage was sent for culture andsensitivity, which showed heavy growth of staphylococcus aureus. Theorganisms were found to be sensitive to amoxicillin with clavulanic acid, sothe same antibiotic was continued for 7 days.

Discussion:Boil or furuncle is the acute infection of the hair follicle by

staphylococci. In the external auditory canal hair follicles are only presentin the outer one-third part. Boil in the ear is usually single but multiple boilscan occur sometimes. The predisposing factors are diabetes mellitus, generaldebilitating diseases, scratching of the external auditory canal, swimmingand poor hygiene.

Following points are important to remember in case of boil in theear:1- Recurrent boil is common in patients having diabetes mellitus. Thus if

any patient comes with recurrent boil, diabetes mellitus should be excluded.2- During incision and drainage of the boil ear, incision is always given

parallel to external auditory canal. The circumferential incision at theexternal auditory meatus may lead to stenosis later on, so it should beavoided.


4


5

TEST YOURSELFRead the clinical scenario given at the beginning and answers the following questions

1- What is the most likely diagnosis in this case?2- What are the differential diagnosis in this case?3- How will you investigate this case?4- How will you manage this case?5- What are the important points to remember in a case of boil in the ear?

3- Boil in the ear is a very painful condition because the skin is tightlyadherent to the underlying cartilage.

A mother brought her 4 years old son with the complaint that he had insertedsomething in his right ear 3 hours back. She tried to remove it with a forceps, whichresulted in further pushing of the foreign body deeper in the canal. He was alsocomplaining of mild pain in his right ear. Otoscopy showed foreign body (a bead)impacted deeper in his external auditory canal (fig. 2.1)

Clinical Scenario

Fig. 2.1Otoscopic finding showing a foreignbody in the external auditory canal

Important points in history taking:1- Inquire about nature of the foreign body, whether it was vegetative or

non-vegetative, metallic or non-metallic, smooth or sharp, rounded orirregular etc. In this case nature of the foreign body was not known.

2- Duration of foreign body insertion. In this case it was three hours.3- Any attempt of removal by family member or family doctor. Unskilled

attempt for removal may cause further pushing of foreign body deeperand trauma to the surrounding structures. In this case there was historyof removal of the foreign body by patients mother herself.

4- Any bleeding from the ear.5- Pain in the ear. Pain is caused by pressure of the foreign body or trauma

to external auditory canal or ear drum.

Important points in clinical examination:1- Assess the site of impact.2- Confirm the nature of foreign body.3- Any trauma or bleeding present in the external auditory canal.4- General condition of the child, whether he is anxious or co-operative.

Removal of foreign body in an anxious and unco-operative child may


Case 2

6

cause more trauma. So it is always better to remove foreign body undergeneral anaesthesia.

Diagnosis:This was a case of impacted foreign body in right external auditory

canal.

Investigations:No investigation is required in otherwise healthy child in such an

emergency situation.

Treatment:Patient was admitted for removal of foreign body under general

anaesthesia, as he was crying and very anxious, even not allowing properexamination. Under general anaesthesia foreign body was removed by passinga ring probe beyond the foreign body and pulling it out (fig. 2.2).

Discussion:Foreign bodies in the ear may be animate such as insects or inanimate.

Inanimate foreign bodies are usually introduced by children and mentallyretarded persons by themselves. Inanimate foreign body may be hygroscopicor vegetative like seeds or non-hygroscopic or non-vegetative like metals,plastic and other materials. A hygroscopic foreign body absorbs water andmoisture present in the canal and swells up and gets impacted in the canal.Isthmus of the external auditory canal is the narrowest part and most of theforeign bodies are impacted at isthmus.

Method of removal depends upon the size, site of impaction and typeof foreign body. Removal under general anaesthesia is essential in childrenand sensitive adults. Smooth and rounded foreign body is removed by a ringprobe. Forceps must not be used in such foreign bodies as it can push theforeign body further in.

Fig. 2.2Method of removal of a rounded

foreign body by ring probe


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8


1- How will you manage this patient?2- What are the options for removal of foreign body from the external auditory canal?3- Classify foreign bodies of the external auditory canal.4- What is the narrowest part of external auditory canal?

A 27 years old male patient came with the complaints of blockage of the rightear after swimming in the pool on a picnic 2 days back, which was continous and same.He also had mild pain and discomfort in his right ear.

Clinical Scenario

Important points in history taking:1- Any discharge from the ear. No discharge was present in this case.2- History of cold or sore throat before going to swimming. There was no

such history.3- Itching in the ear. Slight itching was present in this case.4- Use of ear plugs during swimming. He had not used ear plugs during

swimming.5- Any history of bleeding from the ear. There was no history of bleeding

from the ear.

Important points in clinical examination:1- Ear examination with the speculum and otoscope. Showing accumulation

of dark brown wax in the external auditory canal (fig 3.1).2- Suction cleaning of the ear and inspection of the tympanic membrane.

Wax was not possible to be removed by suction as it was impacted andhard.

3- Tenderness over pinna, tragus and mastoid area. There was no tendernesson any area in this case.

4- Tuning fork tests. Rinnes test was negative in right and positive in leftear, Webers test was lateralized to the right and Schwabachs test wasequal to the examiner on both the sides.

Fig. 3.1Otoscopic finding of the right ear


Case 3

9

5- Examination of the nose and throat for any pathology. No positive findingwas present in these areas.

Diagnosis:The diagnosis in this case was impacted wax in the right ear.

Differential Diagnosis:1- Otomycosis, where wet newspaper like mass is seen in the canal.2- Traumatic perforation of the ear drum.3- Otitis externa or boil. It is very painful and tenderness is present over

tragus and pinna.

Investigations:No laboratory investigation was done in this case as the diagnosis

was clear. In case of suspected otomycosis, removed debris from the earshould be sent for fungal smear.

Treatment:Wax was first softened by instilling a softening agent like 2% soda

glycerine ear drops thrice daily for 2 days and suction cleaning was donelater on (fig 3.2). After suction cleaning of the ear, tympanic membrane andexternal auditory canal were found to be normal and patient had normalhearing.


10

Fig. 3.2Suction cleaning of the wax

Discussion:Wax or cerumen is the mixture of the secretions of ceruminous and

pilo-sebaceous glands. These glands are present only in the cartilagenousportion of external auditory canal.The proportions in the mixture determinethe consistency of the wax. When secreted it is thick and golden brown incolour, which becomes darker and hard on drying. Normally it is expelledfrom the canal in flakes, aided by the movement of jaw. Plug formation isencouraged by excessive formation of wax and its retention by stiff hairs,


11

exostosis, desquamation and other stenosing conditions. The options for theremoval of soft wax are:1- Syringing (fig. 3.3)2- Suction cleaning (fig. 3.2)


1- What are the differential diagnosis in this case?2- How will you manage this case?3- What is wax and how it is formed?4- What are the signs and symptoms of a patient having impacted wax in the ear?5- What are the different options for removal of impacted wax in the ear?

Fig. 3.3Syringing of the ear in another patient

Clinical Scenario

Important points in history taking:1- Whether it was present at birth. In this case it was present at birth.2- Any history of discharge from the opening or redness and pain of the

surrounding area. In this case there was history of occassional dischargewith redness and pain around the opening for which she takes medicines.

3- Unilateral or bilateral. In this case it was bilateral.

Important points in clinical examination:1- Assess whether it is infected or not. At time of presentation there was no

sign of infection except skin was slightly red and congested.2- Any other opening in external auditory canal. There was no other opening.3- Assess for any other congenital abnormality of the ear. All other areas

were within normal limits.

Diagnosis:This was a case of Pre-auricular sinus.

Investigations:1- Pus or discharge for C/S. This patient when presented has a dry opening

so C/S was not done.


Case 4

12

Fig. 4.1Left ear showing a small hole or

opening with redness and swelling infront of the crus helix

A mother brought her 10 years old daughter with the complaint that she had asmall hole in front of her ear on both the sides since birth (fig 4.1). There was historyof repeated discharge often white or yellow in colour from these openings, which settleddown with medication from local general practitioner. Discharge was often associatedwith pain and redness in front of the ears.

2- Other baseline investigations for general anaesthesia when planned forsurgery like blood complete picture, ESR, random blood sugar, urine D/Rand X-ray chest (PA view).

3- Sinogram: It is done to delineate the whole sinus and its tract. In routinecases it is not indicated, so it was not done in this case.

Treatment:Surgery was planned after investigation. Under general anaesthesia

an elliptical incision was given (fig. 4.2). Whole tract and opening of thesinus was excised and wound was closed in two layers.


13

Discussion:Pre-auricular sinus is a congenital condition and is due to failure of

complete fusion between the first and second branchial arch elements in theauricle. External opening of pre-auricular sinus is situated between the tragusand crus helix.


1- What is your diagnosis in this case?2- How will you manage this case?3- What is a pre-auricular sinus and how is it formed?4- What is the location of external opening of pre-auricular sinus?

Fig. 4.2Elliptical incision was marked before

surgery

Clinical Scenario

Important points in history taking:1- Detailed history regarding itching and discharge. Itching was severe and

continuous present all the time. Discharge was scanty, creamish to yellowin colour, thick and often contained blackish spots. It was never bloodstained.

2- Previous history of discharge. There was no history of discharge in thepast.

3- History of swimming. He went to a picnic spot where he did swimmingin a small swimming pool about three weeks back. He had not used earplugs during swimming.

4- Any history of pain. There was no pain in the ear.5- Any history of deafness or blockage of the ear. According to him his right

ear was blocked since the start of these symptoms.6- Any history of diabetes mellitus or any immuno-compromised state.

There was no such history.7- Habit of scratching the ears with different objects. There was no such

history in this case.

Important points in clinical examination:1- Examination of the external auditory canal and tympanic membrane.

External auditory canal was full of creamish yellow debris with brownishblack spot (fig. 5.1). Tympanic membrane was not visible.


Case 5

14

Fig. 5.1Otoscopic findings of the right ear

A 24 years old male patient came with the complaints of severe itching anddischarge from his right ear for last 10 to 12 days. On clinical examination, otoscopicfindings are shown in fig. 5.1.

2- Voice test. Mild deafness was present in the right ear.3- Tuning fork tests. Rinnes test was negative in the right ear and positive

in the left ear. Webers test was lateralized towards the right side andSchwabachs test was equal to the examiner on both sides.

4- Suction cleaning of the debris done and examination of the externalauditory canal and tympanic membrane was done, which were bothoedematous and congested.

Differential Diagnosis:1- Otomycosis2- Impacted wax in the ear3- Other types of otitis externa

Investigations:1- Debris removed from the external auditory canal was sent for fungal

smear, which showed presence of fungal hyphae, confirming the diagnosis.

Diagnosis:This was a case of otomycosis or fungal infection of the external

auditory canal.

Treatment: Suction cleaning of the external auditory canal was done completely.

Clotrimazole lotion (anti-fungal drops) was given for topical application inthe right ear, three times a day. Patient was advised for dry mopping of theexternal auditory canal before instilling lotion in the ear. Regular follow-upwas done and once again suction cleaning was done after 4 days. Patientsear became normal and dry within ten days.

Discussion:Otomycosis is the fungal infection of the lining skin of external

auditory canal. Swimming in the dirty water or continuous discharge due tootitis media, are important predisposing factors. Aspergillus is the mostcommon type of fungus causing this condition but in some cases candidaalbicans is the causative organism. Secondary bacterial infection is verycommon which causes pain. On examination the external auditory canal isfilled with a wet news paper or blotting paper like mass and its colour dependsupon the type of fungus.


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1- What is your diagnosis in this case?2- How will you manage this patient?3- What are the different varieties of fungus causing otomycosis?

Clinical Scenario

Important points in history taking:1- Detailed history regarding his symptoms. According to his father, patient

was completely alright 3 days back, when he complained of pain in hisright ear. Next day he also had some discharge from his right ear alongwith pain. He took some medicines from his family physician and painsubsided. Next day patient again had severe pain and discharge alongwith blood.

2- Previous history of discharge. There was no history of discharge in thepast.

3- Any history of trauma, scratching or foreign body insertion. There wasno such history.

4- Any history of cold, fever, sore throat or respiratory tract infection. Therewas no such history.

5- Socio-economic and hygienic condition. They lived in a village with verypoor hygienic condition with lots of house flies and mosquitos.

Important points in clinical examination:1- Examination of the right ear. There was discharge and blood coming out

from the right external auditory canal (fig. 6.1). Patient had severetenderness over the pinna and surrrounding area. All discharge and bloodcleaned from the external ear and external auditory canal. There weremany maggots present in the external auditory canal (fig. 6.2).


Case 6

16

Fig. 6.1Patient with severe pain, discharge and

bleeding from the right ear

A father brought his 2 years old son with the complaints of severe pain, dischargeand bleeding from the right ear for last 2 to 3 days (fig. 6.1). He took medicines fromhis family physician but there was no relief and the condition was worsening.

Diagnosis:This was a case of Maggots in the ear.

Treatment: Patient was admitted in the hospital. Few drops of maggot oil were

instilled in the right ear and maggots removed. All debris and discharge alsocleaned from the external auditory canal and pack soaked in antisepticointment was applied. Broad spectrum parenteral antibiotic was started alongwith analgesic. Daily dressing and cleaning of the external auditory canalwas done. Subsequent recovery was uneventful.

Discussion:Maggots are the larvae of housefly. These flies are attracted by the

foul smelling discharge present in the ears or nose and lay their eggs intothe external auditory canal or nasal cavity. Within 24 hours these eggs hatchedout into larvae or maggots. Maggots produces severe pain, irritation, swelling,foul smelling and blood stained discharge. On examination maggots arevisible crawling in the external auditory canal. They may cause extensivesoft tissue necrosis.

Treatment consist of removal of all the maggots with forceps butthey are usually firmly attached to the meatal wall. Maggot oil (turpentineoil) or chloroform water is instilled which causes asphyxia and killing ofmaggots thus facilitating their removal.


17


1- How will you manage this patient?2- What are maggots?3- Outline clinical features of maggots in the ear.

Fig. 6.2Maggots removed from the patients

right ear

Clinical Scenario

Important points in history taking:1- Detailed history regarding pain like character, nature, site, severity,

radiation, aggravating and relieving factors etc.2- Any history of fever. In this case there was history of fever since yesterday.3- Any history of present or previous discharge from the ear. There was no

such history in this case.4- Any history of deafness or hearing impairment. On inquiry child mentioned

about the blockage or hearing impairment in his right ear.5- Any history of sore throat, cold, nasal obstruction, nasal discharge, post-

nasal dripping etc. In this case there was history of common cold for lasttwo days.

6- Any history of scratching of the external auditory canal, foreign bodyinsertion, swimming or entry of water during bathing. In this case therewas no such history.

Important points in clinical examination:1- Inspection of the pinna, external auditory canal, mastoid area, pre-auricular

region along with palpation for tenderness in these areas. All were withinnormal limits.

2- Examination of tympanic membrane with speculum and otoscope. In thiscase tympanic membrane was congested and bulging, more prominently


Case 7

18

A mother brought her 7 years old son with the complaint that his son was notlooking well since yesterday, when he went to bed early. At midnight he woke up withthe complaint that he has severe pain in his right ear. She gave him syrup paracetamoland put some eardrops in his right ear, after that he slept again. Next morning when hewoke up he was again complaining of severe pain in his right ear.

Fig. 7.1Otoscopic picture of tympanic

membrane on right side showingcongested and bulging tympanic

membrane

in its posterior half (fig. 7.1).3- Tuning fork tests. It was not done in this case because of severe pain and

anxiety.4- Examination of the nose and throat. In this case both nasal cavity and

throat were congested with secretions in both nasal cavities.

Diagnosis:This was a typical case of acute suppurative otitis media. Pain usually

starts in the night during sleeping, when the ear is in dependent positionalong with venous stasis and reduced eustachian tube opening.

Differential Diagnosis:In a child of 7 years following conditions have to be differentiated

with acute suppurative otitis media:1- Diffuse otitis externa and boil in the ear. These two conditions may

present with acute pain but the pain is not deep seated as in case of acutesuppurative otitis media. In addition there will be tenderness on the tragusand pinna with oedema or swelling in the external auditory canal. Tympanicmembrane will be normal with no hearing loss.

2- Referred earache. In such cases tympanic membrane and external auditorycanal are normal with no deafness or discharge. Look the other areas forreferred earache like oral cavity, tonsils, pharynx, teeth, nose and neck.

Investigations:No investigation was done in this case as the diagnosis was clear.

Pus is sent for culture and sensitivity in cases of tympanic membraneperforation with discharge or in cases where myringotomy is done forevacuation of pus.

Treatment:The patient was planned for medical treatment first. Following

treatment was given and the patient was followed up for improvement.1- Antibiotic (amoxicillin with clavulanic acid) in suspension form was

given according to body weight of the patient.2- Syrup ibuprofen with psuedoephedrine.3- Steam inhalation, twice daily for 10 minutes each.

Patient responded well on the above mentioned treatment and therewas no need for myringotomy.

Discussion:Acute suppurative otitis media is the acute inflammation of the lining

mucous membrane of the middle ear cleft. Clinically it is divided into thefollowing four stages:1- Stage of tubo-tympanitis2- Stage of catarrhal inflammation3- Stage of suppuration


19


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4- Stage of resolution or complicationThis patient presented in the stage of suppuration where frank pus

was present in the middle ear with bulging of the tympanic membrane.Myringotomy is often needed in this stage to evacuate the pus from themiddle ear when bulging of tympanic membrane is more or in cases whereno improvement occurs with medical treatment. The common micro-organismresponsible for acute suppurative otitis media are:1- Streptococci2- Pneumococci3- Haemophilus influenzae4- Morexella catarrhalis

The final outcome or sequelae of acute suppurative otitis media maybe:1- Infection may halt at any stage with complete resolution.2- Ruptured tympanic membrane may heal with return of normal hearing.3- Ruptured tympanic membrane may heal with thin paper like membrane

with scarring and some residual hearing loss.4- Ruptured tympanic membrane may not heal and residual dry perforation

remains with conductive hearing loss.5- Acute inflammation may change into chronic suppurative otitis media

(tubo-tympanic type).6- If the condition is not treated properly, complication may arise due to

spread of infection to other sites.


1- What are the important points in history taking and clinical examination in this patient?2- What is the most likely diagnosis in this case?3- What are the differential diagnosis in this case?4- How will you manage this case?5- What are the different stages of acute suppurative otitis media?6- What are the common micro-organisms responsible for acute suppurative otitis media?7- What are the possible outcomes or sequelae of acute suppurative otitis media?

Clinical Scenario

Important points in history taking:1- Detailed history about discharge from the ear i.e. onset, continuous or

intermittent, amount, colour, foul smelling, blood stained, aggravatingand relieving factors etc. In this patient, discharge was present for thelast many years. It was almost continuous, profuse, yellow in colour andfoul smelling. Discharge reduces in amount whenever he takes medicinefrom the general practitioner for few days and then after becomes thesame.

2- Detailed history about the mass like its onset and progression. He toldthat few months back he noticed heaviness and something in his left earcanal. Gradually that mass increased in size and later it came out of theear canal upto its present size. There was occassional bleeding from themass whenever he tried to clean the mass.

3- Detailed history regarding deafness and pain. Deafness was present sincethe start of discharge but initially it was mild and it increased graduallyand now he has marked hearing loss. Regarding pain, it occurred off andon and relieved by taking medicines.

4- Any history of fever, headache, altered conciousness, vomiting, neckstiffness or any other neurological symptom. In this case there was nosuch history.


Case 8

21

Fig. 8.1A reddish mass coming out from theexternal auditory canal along with

purulent discharge

A 16 years old boy came in the OPD with complaint of some mass in the leftear for last few months. On inquiry he said that there was history of discharge from theleft ear for last many years. Now he also had marked deafness from his left ear. Onclinical examination a reddish mass was seen coming out from the left external auditorycanal along with profuse purulent discharge (fig. 8.1).

Important points in clinical examination:1- General physical examination. It showed that the patient was a young,

average built boy sitting comfortably and fully oriented in time, spaceand person.

2- Inspection of the external ear. It showed a reddish, irregular, smoothsurface, shiny mass filling the external auditory meatus and coming outfrom the canal. There was also yellowish muco-purulent discharge aroundthe mass and adjacent pinna.

3- Examination of the post-aural region. There was no significant findingand this region was normal.

4- Probe test of the mass. It showed that the mass is soft, mobile and appearsthat it was not attached to the external auditory canal and pedicle wasdeep seated. It did not bleed on touch.

5- Examination of the discharge. It was present around the mass in theexternal auditory canal and adjacent pinna. Pus was profuse, yellow incolour, mixed with mucous, foul smelling but not blood stained. Pus wascollected on a sterile swab and sent for culture and sensitivity.

6- Examination of the tympanic membrane. It was not visible because ofthe mass.

7- Voice test, showed moderate degree of hearing loss.8- Tuning fork tests. Rinnes test was negative in the left ear and positive

in right ear. Webers test was lateralized towards the left side andSchwabachs test was equal to the examiner in both ears.

9- Fistula test. It was negative in both the ears.10-Vestibular function tests. All appeared to be within normal limits.11- Examination of the facial nerve. It was found to be intact.12- Examination of the nose and throat. These regions were within normal

limits.

Investigations:1- Pus for culture and sensitivity. It showed mixed growth of pseudomonas

aeroginosa and staphylococcus aureus.2- Pure tone audiogram. It showed moderate to severe conductive deafness.


22

Fig. 8.2X-ray mastoid (Laws view)

3- Plain X-ray mastoid (Laws view). It showed haziness or opacificationin the mastoid region along with a soft tissue mass in the external auditorycanal (fig. 8.2).

4- CT scan of the mastoid bone. This was not done because of un-affordibilityby the patient.

Diagnosis:This was a case of aural polyp, a complication of chronic suppurative

otitis media most likely tubo-tympanic type.

Treatment:The patient was planned for aural polypectomy and mastoid exploration

under general anaesthesia. The pedicle of the polyp was lying deep, it washold and cut by a crocodile forceps and the polyp removed completely.Tympanic membrane was found to have a large sized central perforation.Through a post-aural approach mastoid antrum was opened and corticalmastoidectomy was done. Disease was cleared from the mastoid antrum andmastoid air cells. Myringoplasty was also done at the same time by usingtemporalis fascia graft. Post-operative recovery was uneventful.

Discussion:Chronic suppurative otitis media is the chronic inflammation of mucosa

of the middle ear cleft. This is conventionally divided into two main clinicaltypes:1- Tubo-tympanic type2- Attico-antral type

Tubo-tympanic type is virtually always a complication of acutesuppurative otitis media. It is the safe variety and relatively more commonthan the attico-antral type. Serious complications are rare in tubo-tympanictype. With prolonged discharge a polyp may form in the middle ear andcomes out through the perforation. Some times polyp is so large that it comeout through the external auditory meatus like in this case. Polyp is formedbecause of extensive oedema in the mucous membrane as a result of chronicinflammation.


23


1- What is the most likely diagnosis in this case?2- How will you manage this case?3- See fig. 8.1 and describe its findings.4- See X-ray in fig. 8.2 and describe its findings.5- What are the different types of chronic suppurative otitis media?5- What is an aural polyp? and how it is formed?

Clinical Scenario

Important points in history taking:1- Detailed history about discharge from the ear i.e. onset, continuous or

intermittent, amount, colour, foul smelling, blood stained, aggravatingand relieving factors etc.

2- Detailed history regarding deafness and pain in the ear. Deafness waspresent since the start of discharge but initially it was mild and it increasedgradually and now he has marked hearing loss. Regarding pain, it occurredoff and on and relieved by taking medicines but now for last few daysit is continuous and moderate to severe which was not relieved by takinganalgesic drugs.

3- Any history of fever, headache, altered conciousness, vomiting, neckstiffness or any other neurological symptom. In this case there was nosuch history.

Important points in clinical examination:1- General physical examination. It showed that the patient was a young,

average built person sitting comfortably and fully oriented in time, spaceand person.

2- Examination of the discharge. It was present in the external auditorycanal, scanty in amount, thick yellowish in colour, purulent, foul smellingand blood stained. Pus was cleaned completely from external auditorycanal and sent for culture and sensitivity.

3- Examination of the tympanic membrane. It showed postero-superiormarginal perforation with whitish material (most likely cholesteatoma).Granulation tissues were also seen anterior to it. There was alsoinvolvement of the attic region or pars flaccida (fig. 9.1)

4- Examination of the post-aural sulcus and mastoid region for any swelling,redness, sinus or tenderness etc. These areas were appeared to be withinnormal limits.

5- Voice test. It showed moderate degree of hearing loss.6- Tuning fork tests. Rinnes test was negative in right ear and positive in

left ear. Webers test was lateralized towards the right side and Schwabachstest was equal to the examiner in both ears.

7- Fistula test. It was negative in both the ears.


Case 9

24

A 24 years old male patient came in OPD with the complaint of thick, foulsmelling and occasional blood stained discharge from his right ear for last one year. Healso had marked hearing impairment and for last few days he had moderate to severepain in his right ear.

8- Vestibular function tests. All appeared to be within normal limits.9- Examination of the facial nerve. It was found to be intact.

Investigations:1- Pus for culture and sensitivity. It showed heavy growth of pseudomonas

aeroginosa.2- Pure tone audiogram. It showed moderate conductive hearing loss (about

40-50 dB) on the right side (fig. 9.2)3- Plain X-ray mastoid (Laws view). Showed a lytic lesion (most likely

cholesteatoma) in the mastoid bone (fig. 9.3).4- CT scan of the temporal bone and brain. This was not done because of

un-affordibility by the patient.

Diagnosis:This was a case of chronic suppurative otitis media most likely with

cholesteatoma (attico-antral type), causing bone and ossicular erosion.

Differential Diagnosis:1- Tubo-tympanic type of chronic suppurative otitis media.2- Chronic suppurative otitis media with complication.


25

Fig. 9.1Tympanic membrane showing postero-

superior marginal perforation withcholesteatoma and granulation tissues

Fig. 9.2Pure tone audiogram showing moderate

conductive hearing loss

Treatment:The patient was planned for mastoid exploration under general

anaesthesia. Through post-aural approach mastoid antrum was opened.Extensive cholesteatoma was found involving middle ear, additus, mastoidantrum and mastoid air cells. Modified radical mastoidectomy (canal walldown) was done and all the disease was removed. Long process of incus wasfound to be necrosed by the cholesteatoma but other ossicles were foundintact. Tympanoplasty was also done at the same time. Post-operative recoverywas un-eventful.

Discussion:Chronic suppurative otitis media is the chronic inflammation of mucosa

of the middle ear cleft. This is conventionally divided into two main clinicaltypes.:1- Tubo-tympanic type2- Attico-antral type

Tubo-tympanic type is virtually always a complication of acutesuppurative otitis media. It is the safe variety and relatively more commonthan the attico-antral type. Attico-antral type is considred as dangerous varietybecause of its aggresive nature and presence of cholesteatoma.

Cholesteatoma is a bag of stratified squamous epithelium whichcontains keratin debris, shed epithelium and bacteria. It has tendency ofexpansion and causing necrosis of the neighbouring structures and bones.There are four theories for the formation of cholesteatoma:1- Congenital cell rest theory2- Metaplastic theory3- In-growth of squamous epithelium theory4- Retraction pocket theory

Cholesteatoma if not treated may give rise to following complications,which are broadly classified into:1- Extra-cranial complications:

a- Mastoiditisb- Labyrinthitis


26

Fig. 9.3Plain X-ray mastoid (Laws view)

showing cholesteatoma


27


1- What is the most likely diagnosis in this case?2- What are the differential diagnosis in this case?3- How will you investigate this case?4- How will you manage this case?5- See fig. 9.1 and describe its findings.6- See pure tone audiogram in fig. 9.2 and describe its findings.7- See X-ray in fig. 9.3 and describe its findings.8- What is cholesteatoma? and how it is formed?

c- Facial nerve paralysisd- Petrositise- Otitis externaf- Thrombosis of internal jugular veing- Chronic adhesive otitis media

2- Intra-cranial complications:a- Extra-dural abscessb- Sub-dural abscessc- Brain abscessd- Meningitise- Sigmoid sinus thrombosisf- Otitic hydrocephalus

Clinical Scenario

Important points in history taking:1- Detailed history regarding onset, progression, associated factors,

aggravating and relieving factors etc. Facial paralysis started insidiouslyabout two weeks back. Initially it was very slight and the patient ignoredit but gradually it increased to its present condition. There was noaggravating and relieving factor with no significant associated factor.

2- Any history of ear disease or discharge from the ear. He had history ofdischarge and deafness from his left ear for the last one year. Dischargewas usually scanty, thick, foul smelling and often blood stained. He hasnever consulted to a doctor for his ear complaints.

3- Any history of trauma or head injury. There was no such history.4- Any history of pain in the ear or headache. There was no history of pain

or headache in this patient.5- Any history of change in taste sensations on the tongue. He has not

noticed any change.6- Any history of vertigo. No history of vertigo.7- Motor or sensory weakness in any other part of the body or limbs. There

was no such problem.

Important points in clinical examination:1- General physical examination. It showed that the patient was a young

adult of average built, sitting comfortably and fully oriented in time,


Case 10

28

Fig. 10.1Patient with left sided facial nerve

paralysis

A 33 years old male patient came in OPD with complaint of asymmetry of hisface for the last 2 weeks. On examination he had facial nerve paralysis involving thewhole left side (fig. 10.1). On inquiry he also complained of discharge from the left earfor last one year.

space and person. His vital signs were all within normal limits.2- Examination of motor part of the facial nerve. There was whole left sided

facial paralysis (fig. 10.1).3- Examination of the ears. There was scanty, thick and foul smelling

purulent discharge in the left external auditory canal. After cleaning thepus, tympanic membrane was examined. It showed a large postero-superior marginal perforation with some whitish material in the middleear (probably cholesteatoma). Right ear was within normal limits.

4- Examination of the post-aural region. There was no significant findingand this region was normal.

5- Voice test, showed moderate degree of hearing loss of the left side.6- Tuning fork tests. Rinnes test was negative in the left ear and positive

in right ear. Webers test was lateralized towards the left side andSchwabachs test was equal to the examiner in both ears.

7- Fistula test. It was negative in both the ears.8- Vestibular function tests. All appeared to be within normal limits.9- Taste sensations on the tongue. It showed a decrease in taste sensations

on the left anterior two-third of the tongue.10- Examination of the nose and throat. These regions were within normal

limits.

Investigations:1- Pus for culture and sensitivity from the left external auditory canal. It

showed heavy growth of pseudomonas aeroginosa.2- Pure tone audiogram. It showed moderate to severe conductive deafness

on the left side with normal hearing threshold on the right side.3- Plain X-ray mastoid (Laws view). It showed haziness in the mastoid

region along with bony erosion and cavity formation (finding consistantwith a cholesteatoma).

4- CT scan of the mastoid bone. This was not done because of un-affordibilityby the patient.

5- Electro-diagnostic tests for facial nerve like minimal nerve excitabilitytest, electromyography and electroneuronography. These tests werenot done because of un-affordibility by the patient.

Diagnosis:This was a case of facial nerve paralysis as a complication of attico-

antral type of chronic suppurative otitis media (CSOM with cholesteatoma).

Treatment:The patient was planned for mastoid exploration and facial nerve

decompression under general anaesthesia. Through a post-aural approachmastoid antrum was opened. Extensive cholesteatoma was present in themastoid antrum and mastoid air cells. All the cholesteatoma was clearedfrom these area. The bridge was lowered and modified radical mastoidectomywas done. Cholesteatoma was found to be causing facial canal erosion and


29

compression of the facial nerve at its second genu. All the disease clearedfrom this area and the facial canal was opened around the site of erosion.Nerve was found to be intact so it was covered with a temporalis fascia graft.Post-operative recovery was un-eventful and facial nerve showed improvement.

Discussion:The facial nerve is the seventh cranial nerve and it is a mixed nerve

contains motor, sensory and secretomotor fibres. The cause of facial nerveparalysis is classified into:1- Supra-nuclear paralysis: In this type, only the lower half of the face is

affected while the upper half escapes paralysis. It is because of the reasonthat facial nucleus receives fibres from both side of the cortex controllingupper half of the face.

2- Nuclear paralysis: The facial motor nucleus is affected and the clinicalpicture is similar to that of infra-nuclear type.

3- Infra-nuclear paralysis: The whole side of the face is affected along withother structures supplied by the facial nerve. According to the site ofinvolvement it is further classified into:i- Intra-cranialii- Intra-temporaliii- Extra-temporal or Extra-cranial

The facial nerve is intimately related with the ear, so many ear diseasescan cause facial nerve paralysis. Cholesteatoma because of its bone erosioncapability, is one of the important cause of facial nerve paralysis.


30


1- Look at fig. 10.1 and state facial nerve paralysis is present on which side of the face?2- How will you manage this case?3- Give the classification of facial nerve paralysis.4- What are the important causes of otogenic facial nerve paralysis?

Clinical Scenario

Important points in history taking:1- Detailed history about the first onset of symptoms i.e how it started? In

this patient he did not remember about the first episode of discharge fromthe ear and how it started.

2- Detailed history regarding discharge i.e. how often, amount, colour, foulsmelling, blood stained etc. In this patient ear remained dry for most ofthe time and discharge usually started after swimming and becames dryagain after taking medicines for few days.

3- Detailed history about the hearing impairment and other ear symptoms.In this case he has slight feeling of hearing impairment and occassionaltinnitus on right side.

4- Any history of nasal or throat problem/symptom. In this case there wasno symptom related with nose or throat.

Important points in clinical examination:1- Assessment of perforation. In this patient, perforation was small, rounded,

central and dry involving antero-inferior quadrant of pars tensa (fig.11.1). There was no discharge.

2- Voice test. He heared whisper in both ears i.e. hearing appears to bewithin normal limits.


Case 11

31

Fig. 11.1Dry small central perforation involvingantero-inferior quadrant of pars tensa

A 24 years adult male patient came in the OPD with complaint of recurrentdischarge from his right ear for many years. He was fond of swimming and developedrecurrent ear discharge whenever water went into his right ear during swimming. Hehas to take antibiotic for few days to make his ear dry. At the time of presentation hisear was dry and otoscopic picture of his right ear is shown in fig. 11.1.

3- Tuning fork tests. Rinnes test was positive in both ears, Webers testwas lateralized towards the right side and Schwabachs test was equalto the examiner on both sides.

4- Any signs of middle ear infection. In this patient ear was completely drywith no congestion of tympanic membrane. Middle ear mucosa as seenthrough the perforation also appeared normal.

5- Any pathology in the nose and throat. In this case both nose and throatwere within normal limits with no significant finding.

Diagnosis:This was a case of small and dry central perforation of pars tensa.

Investigations:1- Pure tone audiometry. It showed a conductive loss of 15 to 20 dB especially

in the lower frequencies (fig 11.2).2- Pus for C/S is done when the discharge is present. This patient when

presented has a dry ear so C/S was not done.3- Other baseline investigations for general anaesthesia like blood complete

picture, ESR, random blood sugar, urine D/R and X-ray chest (PA view).All were within normal limits in this patient.


32

Fig. 11.2Pure tone audiogram of the right ear

Treatment: Patient was planned for myringoplasty under general anaesthesia.

As this was a small perforation, fat-plug myringoplasty was planned. Marginsof the perforation were freshened by a needle and fat plug taken from thelobule was tucked in the perforation. Spongestone was applied all aroundand external auditory canal was packed with ribbon guaze soaked in BIPP.Post-operative recovery was uneventful and perforation healed completely(fig. 11.3).

Discussion:The causes of dry perforation of pars tensa includes:

1- Previous acute otitis media with perforation where healing is incompleteresulting in persistant small perforation.

2- Persistant perforation after myringotomy and grommet insertion.3- Tubo-tympanic type of chronic suppurative otitis media where infection

had been settled with medical or surgical treatment but perforation remainsthere.

4- Traumatic perforation where healing is incomplete.Many patients live with small tympanic membrane perforation that

is entirely without symptoms. Symptoms of small and dry perforation includeaudible whistling sounds during sneezing and nose blowing, decreasedhearing and a tendency to infection during cold or when water goes into theear. Hearing loss in small perforation is usually mild and may be unnoticeableby the patients. In swimmers, divers and other water sports enthusiasts,recurrent ear infection may occur. Medical therapy for small pars tensaperforation is directed at controlling ear infection when discharge is presentby giving appropriate systemic antibiotics, aural toilet and antibiotic eardrops. Surgical treatment is repair of the tympanic membrane (myringoplasty).The options for myringoplasty in such a case are:1- Overlay or underlay myringoplasty with graft material like temporalis

fascia. But these two techniques of myringoplasty are more suitable formedium size to large perforations.

2- Fat-plug myringoplasty is very suitable for small perforations like this.3- Repeated cauterization of margins of the perforation with chemicals.


33

Fig. 11.3Tympanic membrane at 6 weeks after

myringoplasty


1- What are the important points in history taking and clinical examination in this patient?2- What investigations will you order in such a case?3- How will you manage this patient?4- What are the different options for myringoplasty?5- What are the advantages of fat-plug myringoplasty?

A 17 years old male patient came with the complaint of impaired hearing fromthe left ear for last 7 to 8 months. It was often associated with crackling and bubblingnoises with sensation of fluid in his left ear especially on changing head position. Therewas no history of discharge or pain in the ear. On examination, otoscopic findings ofhis left ear is shown in fig 12.1.

Clinical Scenario

Fig. 12.1Tympanic membrane of left side

showing fluid in the middle ear withfluid level

Important points in history taking:1- Detailed history regarding deafness. In this patient, deafness was gradual

in onset, continuous but fluctuating in severity and sound appeared quieterbut not distorted.

2- Any history of discharge or pain. In this case there was no history ofdischarge or pain in his left ear.

3- Any symptom related with nose or throat. He had history of recurrentnasal discharge and post-nasal dripping, which was usually relieved bytaking medicines for few days.

Important points in clinical examination:1- Examination of the tympanic membrane. It showed fluid in the middle

ear with fluid level. Tympanic membrane appeared retracted and somewhatcongested with absence of cone of light (fig. 12.1).

2- Valsalvas manuever. There was no affect of Valsalvas manuever on thetympanic membrane of left side i.e. eustachian tube patency was absent.

3- Siegels pneumatic otoscopy. It showed no movement of tympanicmembrane.

4- Voice test. It showed moderate degree of deafness on the left side.5- Tuning fork tests. Rinnes test was negative on the left side and positive


Case 12

34

on the right side. Webers test was lateralized towards the left side andSchwabachs test was equal to the examiner on both sides.

6- Examination of the nose and throat. It did not showed any significantfinding.

Investigations:1- Pure tone audiogram. It showed moderate conductive hearing loss (30-

40 dB in the left ear (fig. 12.2). Right ear showed hearing within normallimits.

2- Speech audiogram. It showed 100% speech discrimination score on boththe side.

3- Tympanogram. It showed type B graph on the left side (fig. 12.3) andtype A graph on the right side.

4- Plain X-ray soft tissue nasopharynx (lateral view) and X-ray PNS (watersview) for any pathology in the nasopharynx, nose and PNS and thesewere within normal limits.

5- Other baseline investigations for general anaesthesia. All were withinnormal limits.

Diagnosis:This was a case of otitis media with effusion in the left ear.

Fig. 12.2Pure tone audiogram of the left ear

showing moderate conductive hearingloss


35

Fig. 12.3Tympanogram of the left side showing

type B graph

Treatment:Patient was planned for myringotomy and grommet insertion under

general anaesthesia. Radial incision was given with myringotomy knife inthe antero-inferior quadrant of the pars tensa. Mucoid fluid came out, whichwas removed by suction and the grommet inserted (fig. 12.4). Post-operativelyantibiotic, analgesic/NSAID and systemic decongestant were given for 2weeks. Patients symptoms improved markedly. Grommet was removed after3 months.


36

Fig. 12.4Tympanic membrane after

myringotomy and grommet insertion

Discussion:The term otitis media with effusion or non-suppurative otitis media

is applied to the clinical condition characterized by the presence of non-purulent fluid in the middle ear cleft. The fluid may be serous, mucoid orsometimes hemorrhagic in nature.

Acute and chronic forms can sometimes be distinguished accordingto the mode of onset or by duration, but the distinction may not always beclear and the condition is often recurrent. In acute form of otitis media witheffusion, duration of the disease is less than 3 weeks and in chronic formduration is longer than 3 months.

From time to time different terminologies have been proposed forthis disease. In 1886 Politzer first described the term otitis media catarrhalis.After the end of the second world war the term glue ear was first introducedby Jordan. The other commonly used synonyms for this condition are secretoryotitis media, serous otitis media, mucinous otitis media, catarrhal otitis media,exudative otitis media and glue ear. It is considered as the most importantcause of deafness in the children world over.

The exact aetiology of this condition is unknown. The followingfactors are described as the aetiological factors for this condition.1- Occlusion of the eustachian tube2- Allergy3- Viral infection4- Unresolved acute otitis media5- Cleft palate


37


1- What is your diagnosis in this case?2- What investigations will you order in this case?3- How will you treat this case?4- Briefly outline the pathology of otitis media with effusion.5- Describe the findings of tympanic membrane as shown in fig. 12.1.6- Describe the findings of pure tone audiogram in fig. 12.2.7- Which type of tympanogram graph is seen in fig. 12.3.8- What is the site of incision for myringotomy in cases of otitis media with effusion?

Clinical Scenario

Important points in history taking:1- Detailed history about deafness i.e. onset, progression, associated factors,

aggravating and relieving factors. According to patient onset was insidious,initially hearing impairment was mild but it increased gradually to thecurrent situation. Deafness was continuous with no fluctuation in severity,with no agrravating or relieving factor. Occasionally it was associatedwith ringing sensations in both ears.

2- Hears better in quiet room or in noisy places. In this patient she had betterhearing in noisy places (paracussis Wallisi).

3- Age of onset. In this patient complaint had started when she was about16 to 17 years of age.

4- Effect of pregnancy on hearing. She had two childrens and according toher, deafness had increased during pregnancy in both the times.

5- History of deafness in the family. According to patient her mother andher elder sister had also similar complaints.

6- Any history of pain or discharge from the ears. In this case there was nohistory of pain or discharge from the ears.

7- Any complaint related with the nose or throat. In this patient there wasno such complaint.

Important points in clinical examination:1- General physical examination. She is a young, fair coloured lady of

average built and fully oriented.2- Examination of the external ear, external auditory canal and tympanic

membrane, all appear to be within normal limits.3- Voice test, showing moderate degree of hearing loss.4- Tuning fork tests. Rinnes test was negative in both the ears, Webers test

was centralized and Schwabachs test was equal to the examiner in bothears.

5- Valsalvas maneuver and Siegels pneumatic otoscopy. It showed patenteustachian tube and tympanic membrane was mobile.

6- Vestibular function tests, all were within normal limits.7- Examination of the nose and throat. No significant finding on it.


Case 13

38

A 28 years old female patient presented with the complaint of impaired hearingfrom both ears for the last 10 to 12 years. She had more problem in hearing in calm andquiet environment as compared to noisy places. There was no history of pain or dischargefrom the ears. On examination her external auditory canal and tympanic membranewere appeared normal in both ears.

Investigations:1- Pure tone audiogram. It showed moderate degree of conductive deafness

in both ears. There was a dip in bone conduction at 2000 Hz (Carhartsnotch) in both ears (fig. 13.1 and 13.2).

2- Speech audiogram. Speech discrimination score was 98% in right earand 96% in the left ear.

3- Tympanogram, showing type As graph in both the ears (fig. 13.3 and13.4).


39

Fig. 13.1Pure tone audiogram of right ear

Fig. 13.2Pure tone audiogram of left ear

Fig. 13.3Tympanogram of right ear

Diagnosis:This was a case of otosclerosis involving both ears.

Differential Diagnosis:The other causes of conductive deafness due to pathology in the

middle ear, should be considered in differential diagnosis, like:1- Congenital fixation of the footplate of stapes. Deafness is present since

birth in this condition.2- Adhesive otitis media. Tympanic membrane will not appear normal

looking and mobile.3- Tympanosclerosis. White chalky patches are seen on tympanic membrane.4- Ossicular dislocation. Type AD tympanogram will be seen in this condition.

Treatment:The patient was planned for stapedotomy and teflon piston insertion

under general anaesthesia on the right side first. Rosens incision was givenand tympanomeatal flap raised. Chorda tympani nerve was reflecteddownwards and postero-superior bony buttress removed. Tendon of stapediusmuscle was cut and supra-structure of stapes removed after fracture. A holeis made in the footplate of stapes and teflon piston (Sheas piston) was


40

Fig. 13.4Tympanogram of left ear

Fig. 13.5Stapedotomy operation with insertion

of teflon piston


41


1- What is the most likely diagnosis in this case?2- What are the differential diagnosis in this case?3- How will you investigate this case?4- How will you treat this case?5- What are the findings on pure tone audiogram in fig 13.1 and 13.2?6- What are the findings on tympanogram in fig. 13.3 and 13.4?7- Outline the steps of stapedotomy operation.8- What is the pathology of otosclerosis?

inserted (fig. 13.5). Post-operative recovery was uneventful with improvementin hearing.

Discussion:Otosclerosis or Otospongiosis is a localized disease of the otic capsule.

There is formation of new spongy bone, which causes ankylosis of the footplateof stapes to the margins of the oval window or may invade to involve thecochlea. This process occurs in the endochondral layer of the bony otic capsule.These bony changes occur at one or more constant sites of otic capsule. Thecommonest site is anterior to the oval window (fissula antefenestrum) causingankylosis of the footplate of stapes to the margins of oval window. Abnormalbone may be present at other sites of otic capsule but usually causes no clinicalmanifestation.

Clinical Scenario

Important points in history taking:1- Detailed history about deafness i.e. its onset, continuous or intermittent,

progressive or not, unilateral or bilateral, hears better in noisy places orin quiet room, associated factors. In this case patient had bilateral,progressive hearing loss and difficulty in understanding speech in thepresence of background noises (this is typically seen in cases of sensori-neural deafness).

2- Any history of discharge from the ears. In this case there was no historyof discharge from the ears.

3- Any history of diabetes mellitus. In this case no history of diabetesmellitus.

4- Occupational history and exposure to loud sound. In this case he was aretired bank manager and there was no history of any occupational noiseexposure or sudden sound like bomb blast or firearm.

5- Any history of using any ototoxic drug. In this case there was no historyof using any drug having such affects.

Important points in clinical examination:1- Examination of the external ear, external auditory canal and tympanic

membrane. All appeared to be within normal limits.2- Voice test. It showed moderate degree of hearing loss.3- Tuning fork tests. Rinnes test was positive in both the ears, Webers test

was centralized and Schwabachs test was less than the examiner in bothear (it means patient has bilateral and equal sensori-neural loss).

4- Vestibular function tests. All were within normal limits.5- Examination of the nose and throat. No significant finding on it.

Investigations:1- Pure tone audiogram. It showed moderate to severe slopping type (i.e.

more pronounced in higher frequencies) sensori-neural deafness in bothears (fig. 14.1 and 14.2).


3- Tympanogram, showed type A graph in both the ears.


Case 14

42

A 68 years old retired bank manager came with the complaint of progressivebilateral hearing impairment for the last few years. He had marked difficulty inunderstanding speech especially in the presence of background noises. On examinationhis external ears and tympanic membranes appeared to be normal.

Diagnosis:This was a case of bilateral sensori-neural hearing loss, most probably

senile deafness or presbyacusis.

Differential Diagnosis:The other causes of sensori-neural deafness should be considered in

differential diagnosis.

Treatment:This was a case of bilateral moderate to severe sensori-neural hearing

loss because of ageing, so following treatment was offered to the patient:1- Hearing aid. Patient was fitted with behind the ear type (BTE), digital

programmable hearing aids in both the ears (fig. 14.3).2- Lip reading and auditory training.

Discussion:The term presbyacusis or senile deafness is used to described hearing

loss resulting from degenerative changes due to ageing. Deafness ischaracteristically bilateral, symmetrical and slowly progressive. It affects both


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the sexes equally. Degenerative changes occur as a result of vascularinsufficiency due to sclerosis, thrombosis or atherosclerosis and involves:1- Hair cells in the organ of Corti2- Neural tissues in the spiral ganglion3- Stria vascularis4- Basal membrane


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1- What is the most likely diagnosis in this case?2- What are the differential diagnosis in this case?3- How will you investigate this case?4- How will you manage this case?5- What is senile deafness or presbyacusis?

Fig. 14.3Behind the ear (BTE) type hearing aid

Clinical Scenario

Important points in history taking:1- Detailed history about deafness i.e. its onset, continuous or intermittent,

progressive or not, unilateral or bilateral, hears better in noisy places orin quiet room, associated factors. In this case, deafness was insidious inonset, continuous, progressive, bilateral and equal in both ears.

2- Occupational history and exposure to loud sound. He was a textile factoryworker and had been working on heavy machines with loud sound 8 to10 hours a day for the past 30 years. There was no facility of any sortfor protection of the ears from loud sound in his factory.

3- Any history of diabetes mellitus. In this case no history of diabetesmellitus.

4- Any history of trauma to the ears or head. There was no such history.5- Any history of using any ototoxic drug. In this case there was no history

of using any drug having such affects.

Important points in clinical examination:1- Examination of the external ear, external auditory canal and tympanic

membrane. All appeared to be within normal limits.2- Voice test, showed moderate degree of hearing loss.3- Tuning fork tests. Rinnes test was positive in both the ears, Webers test

was centralized and Schwabachs test was less than the examiner in bothears (it means patient has bilateral and equal sensori-neural loss).

4- Vestibular function tests. All were within normal limits.5- Examination of the nose and throat. No significant finding on it.

Investigations:1- Pure tone audiogram. It showed moderate to severe slopping type (i.e.

more pronounced in higher frequencies) sensori-neural deafness in bothears (fig. 15.1 and 15.2).


3- Tympanogram, showed type A graph in both the ears.


Case 15

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A 48 years old textile factory worker came with the complaint of impairedhearing from both ears for the past many years. He had marked difficulty in understandingspeech especially in noisy places. There was no history of pain or discharge from theears but occassionally he also had ringing sounds in both ears. On clinical examinationpinna, external auditory canal and tympanic membrane were all normal.

Diagnosis:This was a case of bilateral sensori-neural hearing loss, probably

noise induced hearing loss (NIHL).

Differential Diagnosis:The other causes of sensori-neural deafness should be considered in

differential diagnosis.

Treatment:This was a case of bilateral moderate to severe noise induced hearing

loss, so following treatment was offered to the patient.1- Hearing aid. Patient was fitted with behind the ear type (BTE), digital

programmable hearing aids in both the ears.2- Lip reading and auditory training.3- Protection of the ears from loud sound during working, to prevent further

noise induced hearing loss.

Discussion:Noise induced deafness or hearing loss (NIHL) is caused by prolong

exposure to loud sound. The degree of deafness is proportional to sound intensity


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and duration of daily exposure, though there is a marked variation in individualsusceptibility. OSHA (Occupational Safety and Health Administration, USA)standard for the safe exposure to different sound intensity levels per day for fivedays a week is listed below. These levels are referred to as the permissibleexposure level (PEL).

- 16 hours 85 dB- 8 hours 90 dB- 6 hours 92 dB- 4 hours 95 dB- 3 hours 97 dB- 2 hours 100 dB- 1.5 hours 102 dB- 1.0 hour 105 dB- 30 minutes 110 dB- 15 minutes 115 dB


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1- What is the most likely diagnosis in this case?2- What are the differential diagnosis in this case?3- How will you investigate this case?4- How will you manage this case?5- What are the causes of noise induced hearing loss?6- What is permissible exposure level (PEL) of sound?

Clinical Scenario

Important points in history taking:1- Detailed history about the vertigo. According to the patient it started

suddenly yesterday and since then it was continuous. There was no affectof posture i.e. it remain same on standing, sitting or lying down. Patientwas feeling that all things around him was rotating. There was no specificaggravating or relieving factor. It was associated with nausea and vomittingas well.

2- Detailed history about hearing loss and tinnitus. According to him, bothsymptoms started immediately after start of vertigo. Hearing loss was inright ear, mild to moderate, continuous with no aggravating and relievingfactors. He has ringing sounds in his right ear, which was constant andsame with no aggravating or relieving factors.

3- History of similar attacks in the past. According to patient during the lastthree years he had three to four similar attacks before which lasted fora weak or so and completely improved by medication. There was nocomplaint or symptom in between the attacks.

4- Any history of head trauma, headache or any other neurological symptom.There was no such history.

5- Any history of using any vestibulo-toxic drug. In this case there was nohistory of using any drug having such affects.

6- Any history of allergy. Patient has allergy to multiple things.

Important points in clinical examination:1- General physical examination. The patient was a middle aged man of

average height and obese built, looking anxious but well oriented in time,space and person. His vital signs were within normal range.

2- Examination of the external ear, external auditory canal and tympanicmembrane. All appeared to be within normal limits.

3- Voice test, showed moderate degree of hearing loss on the right side.4- Tuning fork tests. Rinnes test was positive in both the ears, Webers test

was lateralized towards the left ear and Schwabachs test was less thanthe examiner in right ear and equal to the examiner in left ear.

5- Fistula test. It was negative in both the ears.6- Facial nerve examination. It was intact.


Case 16

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A 48 years old male patient came in OPD with the complaints of severe vertigofor last one day. Along with vertigo he has ringing sounds and hearing loss in his rightear. He had history of similar attacks, three or four times before during the last threeyears, which improved by medication and he remained normal between the attacks.

7- Spontaneous nystagmus. It was positive with the fast component towardsthe left side.

8- Gait. Patient deviated towards the right side when he was walking witheyes closed.

9- Rombergs test. Patient swayed on the right side when he was standingwith eyes closed.

10- Cerebellar functions tests like finger nose test, rapid alternating movements(dysdiadochokinesia) and rebound phenomenon, were all within normallimits.

11- Examination of other cranial nerves. All were intact.12-Examination of the nose and throat. No significant finding on it.

Investigations:1- Pure tone audiogram. Showing moderate sensori-neural type of deafness,

equal in all frequencies on the right side and normal hearing on the leftside (fig. 16.1).


3- Recruitment test. It was positive on the right side, showing a cochlearlesion.

4- Caloric test. It was not done because of acute attack of severe vertigo.

Diagnosis:This was a case of Meneires disease.

Differential Diagnosis:The other causes of vertigo should be considered in differential

diagnosis, like:1- Vestibular neuronitis. It usually follows an attack of influenza and hearing

remains normal in this condition.2- Labyrinthitis. It is mostly a complication of chronic suppurative otitis

media or ear surgery. Sometimes labyrinthitis of viral origin can occur.


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3- Benign paroxysmal positional vertigo (BPPV). In this condition vertigoonly occurs in certain specific head positions.

4- Central causes of vertigo.

Treatment:During the acute attack of vertigo, patient was advised strict bed rest

and antivertiginous drugs or labyrinthine sedatives were prescribed. Inaddition patient was advised for:1- Low salt diet2- Avoid excessive intake of water3- Quit smoking4- Avoid stress and bring a change in life style5- Avoid things that are causing allergic reaction The patient became symptom free in ten days. Regular follow-upwas advised and after taking above mentioned precautions, there was nofurther attack of vertigo in the follow-up period of last one year.

Discussion:Menieres disease is the disorder of endolymphatic labyrinth. It is

characterized by sudden paroxysmal attacks of vertigo, deafness and tinnitus. Itinvolves both the cochlear and the vestibular components of the inner ear.

The most consistent histological finding in Menieres disease isdilatation of the endolymphatic compartment of the inner ear. The basicdefect is either over production or diminished absorption of endolymph. Asa result of this scala media is distended with endolymph. Due to over distensionof scala media, rupture of Reissners membrane occurs. This leads to mixingof endolymph and perilymph, which disturbs the cochlear microphonics andaction potentials of the nerves. This occurs because endolymph is a potassiumrich fluid and perilymph is a sodium rich fluid. The attack continues till theruptured membrane is healed and local biochemistry is corrected. The sametype of attack occurs again when the scala media is over distended.


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1- What is the most likely diagnosis in this case?2- What are the differential diagnosis in this case?3- How will you investigate this case?4- How will you treat this patient?5- What is the pathology of Meneires disease and why it occurs in paroxysmal attacks?

Clinical Scenario

Important points in history taking:1- Detailed history regarding vertigo. According to the patient, her symptoms

started after a road traffic accident when she got minor head injury. Shehas feeling of rotation whenever she turned her head to the left whilelying down or rising from the bed. There was no problem on standing,sitting or walking. She also has feeling of nausea and occasionallyvomiting during the attack of vertigo which remained there for fewminutes and she became normal after few minutes. The symptoms wereconstant and same since starting with no aggravating or relieving factorsexcept head movement.

2- Any history of discharge, deafness, tinnitus or any symptom related withthe ear. There was no other complaint.

3- Any history of neck pain or stiffness. There was no such history butoccasionally she felt dizziness on rapid head movement.

4- Any history of trauma or head injury. There was a definite history of roadtraffic accident and head injury and all the symptoms started after that.

5- Past medical history for diseases like hypertension, diabetes mellitus,syphillis etc. There was no history of such diseases.

6- Any other neurologic complaint. There was no such history.7- Drug history. She has used different medicines for these complaints with

no relief and she did not know their names. There was no history of usingany drug before the start of these symptoms.

8- Any history of psychiatric illness. There was no such history.

Important points in clinical examination:1- General physical examination. The patient was a middle aged woman of

average height and built, sitting comfortably and fully oriented. Her vitalsigns were within normal limits and no other positive finding on generalphysical examination.

2- Examination of the ears. Pinna, external auditory canal and tympanicmembrane were all normal on both the sides.

3- Voice test and tuning fork tests. All were within normal limits.4- Examination of all cranial nerves. All were intact.5- Examination for spontaneous nystagmus. It was absent.


Case 17

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A 46 years old female patient came with the complaints of repeated vertigo,nausea and occasional vomiting, lasting for 2 to 3 minutes for last 3 months. The vertigowas exacerbated whenever she turned her head to the left while lying in bed or risingfrom the bed. She has no history of deafness and tinnitus.

6- Gait without and with closed eyes. It was within normal limit.7- Cerebellar function tests. All were within normal limits.8- Dix-Hallpike test. There was nystagmus and feeling of vertigo when the

patient was lowered with head turned towards the left. The nystagmuswas delayed in onset and showed fatigability. There was no nystagmuswith head turned towards the right side.

Differential Diagnosis:The first step in the differential diagnosis of a vestibular disorder is

to delineate between a peripheral or central lesion. The following disordersshould be included in the differential diagnosis of this patient:1- Benign paroxysmal positional vertigo2- Traumatic injury to the labyrinth3- Vestibular neuronitis4- Labyrinthitis5- Menieres disease6- Perilymph fistula7- Acoustic neuroma8- Postural hypotension9- Multiple sclerosis10-Psychiatric illness or use of drugs like tranqulizers

Investigations:1- Baseline investigations like complete blood picture, blood sugar, serum

electrolytes, renal function tests. All were within normal limits.2- Pure tone and speech audiogram. Both were within normal limits.3- Tympanogram. Type A graph was seen on both the sides.4- Caloric test. It was within normal limits on both sides with cold and

warm water.

Diagnosis:This was a case of benign paroxysmal positional vertigo (BPPV),

affected ear being the left side.

Treatment:After all clinical workup, patient was planned for particle repositioning

procedure or Epleys maneuver. It involves sequential movement of thehead into different positions, staying in each position for roughly 30 seconds(fig. 17.1). Initially patient was advised to sit on a couch (position 1). As theaffected ear was left, patients head was rotated to 45o on the left and thenhead was lowered (position 2). Then keeping the patient supine, her headwas rotated 90o towards the right (po

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